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Source of Payment Typology:

A New National Standard

Roxanne Andrews, PhDChair, Source of Payment TypologySubcommittee

Agenda

• Overview of Typology Subcommittee

• Overview of Typology

• Implementation of Typology

• Activities over the Coming Year

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THE SUBCOMMITTEE

Source of Payment Tpology Subcommittee

• Subcommittee of the Data Standards Committee

• Purpose: to create and refine a standard to allow consistent reporting of payer data to public health agencies for health care services and research

• The Payer Typology is an early project for the Consortium (starting in 2000) with continual successes over the years

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Typology Subcommittee

Patricia Andrews

Louisiana State University Health Sciences Center

Louisiana Tumor Registry

Amy Bernstein*

CDC/NCHS

Robert Bolden

Georgia Hospital Association

Robert Davis

Consultant

Sheila Frank

Consultant

Regina Gibson

Blue Cross Blue Shield Michigan

Marjorie Greenberg

CDC/NCHS

Tammara Jean Paul

CDC/NCHS

Hetty Khan

CDC/NCHS

Starla Ledbetter

California Office of Statewide Health Planning and Development

Denise Love

National Association of Health Data Organizations (NAHDO)

Anna Orlova

Johns Hopkins School of Public Health

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Typology Sub-Committee

Charlotte Pease

Maine Health Data Organization

Barbara A. Rudolph

University of Wisconsin - Madison

Cristal Schoenfelder

CA Office for Statewide Health Planning and Development

Gale Scott

Tampa General Hospital

Castine Verrill

CDC/NCCDPHP

Michelle Williamson

CDC/NCHS

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SOP Typology Subcommittee Phases of Activities

• Developed standard payer codes, definitions & user guide

• Worked with national standards groups to have the SOP Typology accepted– ANSI X12– NUBC– HL7 (& PHIN)

Implementation & Education/OutreachMaintenance

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SOURCE OF PAYMENT

TYPOLOGY

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Importance of Source of Payment Data

• Source of payment data used for wide variety of public health and healthcare research

• Critical need for policymakers and researchers examining effects of payment policy to compare across databases

• Standardized source of payment data needed to monitor healthcare trends such as access to healthcare and treatment patterns across payer categories

Payer Coding for National Quality Monitoring

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Risk-adjusted Inpatient Heart Attack Mortality

Payer Coding for Tracking National Hospital Costs

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Issues with Payer in Administrative Data Collected Today

• No uniformity across states• NO DEFINITIONS FOR CONCEPTS• Missing Concepts

– For example: bad debt and charity care

• Overlapping Concepts– For example: Health Maintenance Organization

• Obscure Concepts– For example: Central Certification

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Current Claim Filing IndicatorList Used in 837 Implementation Guides

09 Self-pay10 Central Certification11 Other Non-Federal Programs12 Preferred Provider Organization (PPO)13 Point of Service (POS)14 Exclusive Provider Organization (EPO)15 Indemnity Insurance16 Health Maintenance Organization (HMO) Medicare RiskAM Automobile MedicalBL Blue Cross/Blue Shield

CH Champus CI Commercial Insurance Co.DS DisabilityHM Health Maintenance OrganizationLI LiabilityLM Liability MedicalMA Medicare Part AMB Medicare Part BMC MedicaidOF Other Federal ProgramTV Title VVA Veteran Administration PlanWC Workers’ Compensation Health ClaimZZ Mutually Defined / Unknown

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Solution:Source of Payment Typology

• Designed to improve the organization of the payment categories

• Provides robust definitions

• Hierarchical structure

• Definitions for ALL the concepts

• Companion User Guide for each version of the Source of Payment Typology

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Major Payer Categories

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Medicare

MedicaidOther Government (not Medicare, Medicaid or corrections)

Department of Corrections

Private Health Insurance

Blue Cross/Blue Shield

Managed Care, unspecified (*)

No payment from organization

Miscellaneous/other

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Source of Payment Typology Categories:

Major and Sub-classifications

1 MEDICARE

11    Medicare (Managed Care)

111    Medicare HMO

112    Medicare PPO

113    Medicare POS

119    Medicare Managed Care Other

12    Medicare (Non-managed Care)

121    Medicare FFS

122    Medicare Drug Benefit

123    Medicare Medical Savings Account (MSA)

129    Medicare Non-managed Care Other

19    Medicare Other

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Second Level Sub-classification

2 MEDICAID

21    Medicaid (Managed Care)

211    Medicaid HMO

212    Medicaid PPO

213    Medicaid PCCM (Primary Care Case Mgt)

219    Medicaid Managed Care Other

22   Medicaid (Non-managed Care Plan)

23    Medicaid/SCHIP

24    Medicaid Applicant

25    Medicaid - Out of State

29    Medicaid Other

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Third Level Sub-classification

2 MEDICAID

21    Medicaid (Managed Care)

211    Medicaid HMO

212    Medicaid PPO

213    Medicaid PCCM (Primary Care Case Management)

219    Medicaid Managed Care Other

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Additional Level Classification

32    Department of Veterans Affairs

321 Veteran care--Care provided to Veterans

3211 Direct Care--Care provided in VA facilities

3212 Indirect Care--Care provided outside VA facilities

32121 Fee Basis

32122 Foreign Fee/Foreign Medical Program(FMP)

32123 Contract Nursing Home/Community Nrsing Home

32124 State Veterans Home

32125 Sharing Agreements

32126 Other Federal Agency

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Additional Level Classification

8   NO PAYMENT from an Organization / Agency / Program / Private Payer Listed

81 Self Pay

82 No Charge

821 Charity

822 Professional Courtesy

823 Research / Clinical Trial

83 Refusal to Pay / Bad Debt

84 Hill Burton Free Care

85 Research / Donor

89 No Payment, Other

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IMPLEMENTATION I:Hospital Discharge

Data Systems

States Using the Source of Payment Typology

• Georgia – 2007

• Oregon – 2008

• New York – 2009

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IMPLEMENTATION II:Quality eMeasures

Supplemental Data Elements in eMeasures Include Payer

• Supplemental data elements are included in quality emeasures– To aggregate data to various subgroups– To compare quality across subgroups to

identify disparities

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CMS and National Quality Forum Use Typology as the Value Set for "Payer"

• CMS 2014 Meaningful Use Clinical Quality Measures (CQM) require 4 supplemental data: sex, race, ethnicity, payer

• NQF Measure Authoring Tool for emeasures includes "payer" as default supplemental data

• National Library of Medicine includes Typology in Value Set Authority Center for 2014 CQM

– Raised the issue of "intellectual property" for PHDSC Board 25

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ACTIVITIES OVER THE

COMING YEAR

Maintenance Activities

• Annual maintenance meeting in spring– opportunity for public comments and requests

• Typology categories and / or definitions updated every October (as needed)

• Periodic Subcommittee conference call discussions of impact of insurance system changes on needed payer categories (e.g. from ACA)

Education/Outreach

• Webinars, conference presentations, emails to target audiences– e.g., Webinar Nov 19

• Identify & take advantage of opportunities that arise– e.g., this year- PHDSC letter comments on

the proposed Federal rule on the health plan ID recommended the Typology be included in the CMS registry for the plan ID

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Questions

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